No abstract

Mild systolic hypertension may occur after CAS, but is resolved by medical treatment. Prolonged hypotension and bradycardia may also arise and this can be dangerous because it may cause neurological deterioration due to hypoperfusion. These complications cannot be predicted by clinical, procedural, and angiographic factors.

The study was carried out on a series of 42 patients who underwent surgery through a midline approach. Lesions were in the anterior part of the third ventricle in 32 cases, in the frontal horns in 6, in the trigone in 3, and in both lateral and third ventricles in 1 case. The third ventricle was approached through Monro's foramen in 22 cases and through an interfornicial route in 9 cases. Surgical mortality occurred in 2 cases (5%). Permanent morbidity occurred in another 2 cases (5%): it consisted of slight intellectual deterioration in one case and slight fixed pyramidal signs in the other. Transient mutism was the most frequently observed postoperative complication. Thirty-one patients were reviewed and submitted to neuropsychological tests in the late postoperative period to investigate the presence of intellectual deterioration or disturbances in the interhemispheric transfer of motor, somataesthetic and visual information. All patients showed only the presence of short-term memory disturbance. Furthermore, 12 patients tested before surgery also showed the presence of short-term memory deficits in the preoperative period. We conclude that a midline approach is the most direct and safe route to the third ventricle as well as to the frontal horns and trigone.

There are at present strong indications for surgery in patients suffering from symptomatic extracranial carotid stenoses of > 70%. Surgery of coincidental aneurysms is a still debated problem, but there is general agreement that it is indicated in selected cases according to the patient's life-expectancy and size and site of the aneurysm. The coexistence of these two lesions raises a decision-making problem. We reviewed 389 endarterectomies and found 12 intracranial berry aneurysms in 10 (2.6%) patients. All the 10 patients were harbouring a symptomatic carotid stenosis of > 70%. Since the correction of a stenosis increases blood flow to an aneurysm, our approach was to first operate on the intracranial lesion and then the stenosis in 7 patients harbouring aneurysms > 5 mm. Two patients affected by small aneurysms < 5 mm of an A2 azygos and left internal carotid artery underwent left endarterectomy only. The last patient was submitted first to percutaneous angioplasty of a left stenosis, then to open surgery of a contralateral middle cerebral aneurysm and finally to intravascular occlusion of a small aneurysm of the left internal carotid bifurcation by menas of a coil; this policy was adopted in order to restore normal haemodynamic conditions before the intracranial procedure. There was no mortality or permanent morbidity following surgery for aneurysm or endarterectomy. Transient morbidity occurred in 2 cases after clipping of aneurysms of the anterior communicating and middle cerebral arteries. Our results suggest that surgery of coincidental aneurysms may give good results even when there is a severe symptomatic stenosis in the neck. Moreover, the presence of a small intracranial aneurysm does not seem to be an additional risk factor for endarterectomy. When the lesions are on different sides, it may be better to treat the stenosis first if it decreases the ipsilateral cerebral blood flow.